Monday, February 22, 2010

Man-made Disaster- Non Immunization of Kids

Background: The most cost effective public health intervention is to deliver safe vaccines thorough an efficient delivery system. The main objective of the immunization program is to reduce the mortality and morbidity by vaccine preventable diseases (VPDs). In 1975, the smallpox was successfully eradicated globally by an efficient and effective vaccination program with an effective surveillance. As a result, an expanded immunization program was launched in India in 1978 to control other VPDs. At the very outset 6 deadly diseases were selected: diphtheria, pertussis, tetanus, poliomyelitis, and typhoid and childhood tuberculosis. To begin with, the aim was kept to cover 80% of all infants. Latter on, to universalize the program, it is named in 1985 as Universal Immunization Program (UIP) and measles vaccine replaced the typhoid. The UIP was introduced in phases from 1985 to cover all districts by 1990, targeting all infants with the primary immunization schedule and all pregnant women with Tetanus Toxoid immunization. To make India polio free the National Polio Surveillance Project was started in 1995-96 under the Polio Eradication program

Why act of non immunization is a manmade disaster: A Man-made disasters is a threat having an element of human intent, negligence, or error, or involving a failure of a man-made system. India has made tremendous improvements in health sector in the last thirty years; still lives are lost due to early childhood diseases because of man-made system failure. There are multiple reasons for this but the major factor and the most prominent one is non immunized children against six deadly diseases as per the program. Therefore, more than two millions children die annually as they don’t get vaccinated to develop immunity to fight against these diseases. This is due to bad governance and mismanagement of the health departments. On one hand Health workers are negligent, erroneous and careless towards their duty to vaccinate the children as per the medical norm and on the other hand illiterate and careless parents/guardians are not aware of the dire consequences of non vaccination of their children. These two manmade factors together are taking lives of the kids in spite of availability all required resources. We can prevent these manmade deaths if both medicals workers and parents become aware, alert and dutiful on this issue. If we can eradicate small pox globally, it is almost established and sure that we can save the lives of nearly two million kids by removing and preventing the manmade factors and causes which is costing very heavily in the form of children death.

Outcomes: The infant mortality in India is as high as 58 deaths per 1,000 live births. While the infant mortality rate showed a rapid decline during the 1980s, the decrease has slowed during the past decade. Children in India continue to lose their lives to vaccine-preventable diseases such as measles, which remains the biggest killer. Tetanus in newborns remains a problem in at least five states: Uttar Pradesh, Madhya Pradesh, Rajasthan, West Bengal, and Assam. The number of polio cases in India declined from 1,934 in 1998 to 268 in 2001. There was a setback in 2002 as 1,600 cases were confirmed at the end of the year. But with only 568 cases of polio reported in 2009, however, the proportion of children who receive vaccination against measles has dropped considerably, from 72% in 1995 to a low of 50% in 1999. It now stands at 61%.

Immunization: A large proportion of vulnerable infants and children in India are not receiving this simple intervention. Across India in 2006-07, only 62% of children 12-23 months had received all six of their primary vaccines, with a wide variation across the states. The States with poorer immunization rates are generally the same states with higher infant mortality. India also has the largest number of infants who celebrates their first birthday not fully immunized. Improving routine immunization rates and immunization of incoming newborns will continue to be a decisive element of the overall strategy.

UNICEF ACTIONS: UNICEF provides support for national and state level policy and planning. In addition, UNICEF supports in vaccine and cold chain management, procurement, supplies and capacity building of health workers, cold chain handlers and program managers. The specific activities of the UNICEF team which includes playing a catalytic role, facilitation and assistance to: 1) The State level review and planning meeting on routine immunization. 2) To provide directions from the state level to the districts. 3) Review of vaccine, AD syringes and cold chain logistics and requesting from GoI. 4) Advocacy with the Chief Secretary / Principal Secretary (Health) /Director General (Health)/ Divisional Commissioner / District Collectors / Health Minister / Chief Minister for bringing routine immunization on top of the agenda amongst various health programs. 5) Managing Information Education and communication(IEC)activities. 6) Monitoring Immunization Week (IW) activities and its feedback to enable corrective action.

New UNICEF action: Proposal for Strengthening Routine Immunization in Uttar Pradesh. Immunization Program of Uttar Pradesh is one of the largest in the country in terms of quantities of vaccine used, number of beneficiaries, number of immunization sessions organized and the geographical spread and diversity of areas covered. The success of the immunization program is crucial for the expansion of other public health interventions too. Both UIP and National Rural Health Mission (NRHM) targets to provide equitable, efficient and safe immunization services to all infants and pregnant female. NRHM , 2005-12, seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. In this also on the top is the state of Uttar Pradesh.

The primary objective of the immunization program in the state of Uttar Pradesh is to:

Opportunities in UP: The opportunities that are available in the present context of UP are:1)The District Level Household and facility Survey (DLHS-3) data provides a base that if the children reached with BCG vaccine are being tracked subsequently in RI sessions in a systematized way then we can reduce the drop-out rate significantly and thereby having more Fully Immunized children with attainment of Million Development Goals-4. 2) Use of Newborn Tracking Booklet (NBTB) used in every supplementary immunization activities (SIA) round provides a base for updating the mother child and health (MCH) register with beneficiaries for subsequent tracking for RI doses. 3) Funding available through NRHM addresses the issue of operational and administrative support towards financial and human resource investments.

Problem Statement: The program constraints in UP is multi-pronged. They can be enumerated as: 1) Low demand for immunization services. Lack of public knowledge is a key barrier to immunization i.e. unaware, careless, and, illiterate parents and guardians. 2) Monitoring and weak supervisory and erroneous practices remain problematic i.e. mismanagement and bad governance and failure of a man-made system. 4) Insincerity, carelessness and lack of up-to-date knowledge of health workers.

Strategies: The strategies that have planned towards RI vision for the state and detailed in NRHM yearly project implementation plan (PIP) document are: 1) to reach the underserved or hard to reach populations. 2) to reduce drop-outs and missed opportunities, fixed-day fixed site, integration with private sector. 3)To increase the demand for services of those who have historically participated in routine immunization, but whose interest might be decreasing due to insufficient institutional support for RI: 1)Print media and other mass media systems are effective strategies for raising awareness and influencing behavior. Inter-personal communication (IPC) with families and communities is also critical in bringing about the desired change in attitude and behavior of service users. 2) IPC through ANMs(Auxiliary nurse midwife), AWWs(Agan Wari Workers), local mobilizes and influential persons; IEC material for providers as well as clients.

Innovations done in the State: Many innovations have been done in the state of UP to deduce and establish systems to address the existing problems in Routine Immunization and work in the line of proposed strategies in the state. The two relevant are: 1) the Quality Micro planning has been done in the State with support from UNICEF, WHO/NPSP and CARE in all the 71 Districts of the state using Polio SIA micro plan as base. 2) the “Tracking Every Newborn (TEN)” Initiative was initiated by WHO/NPSP in eight blocks of RI Supported eight NPSP district for tracking every newborn through computerized name based database. This initiative utilizes the newborn data generated through polio SIA as well as other sources to have a comprehensive list.

Proposal: Keeping in view the above problem statement and innovations taken up in the state by Government of UP and Partners, it is proposed that a system of tracking of children in the State needs to be adopted:1)Survey for the eligible beneficiaries in the area will be conducted by ASHA with support of AWW utilizing the ANM of that particular sub centre. The data generated in the filed will be entered in Block Level Computers to generate the soft copies of the beneficiaries. 2) For scaling up the benefits of TEN initiatives, software may be developed with support from NIC which captures the benefits of both the innovations. Technical aspect of the software for its correctness may be requested from WHO/NPSP. 3) The filled-in session tally sheet when entered into the software for vaccination status of the beneficiaries will generate the monthly report for the block which will be transmitted to the District for preparing the monthly report for the district. 4) A monitoring system will have to be inbuilt using the Block Medical Officers and District Medical Officer supervision and monitoring, so that the system can be sustained. 5) Meeting with Directorate Program Officers will be done prior to implementation of the project and Quarterly review of progress made by the districts will be review during the District Immunization Officers RI Review Meeting in the State. UNICEF country office is working closely with ministry of health and family welfare of GoI and state governments, UN system organizations, local and international NGOs to reduce to effect of this manmade disaster on war footing. Now, our focus is the most difficult state UP to make it 100 % immunized to bring the kids to almost nil. After assessing field feasibility in the first year, we well implement across the country from the next year.

For implementing above described proposed system of tracking of children, we need huge money. For this, we are making effort at our level best to have the donations, but it seems difficult as mostly donor has already helped generously in the polio eradication program. Our efforts with governments and partners are continuing to save the lives of dying children by improving the immunization status i.e. by minimizing the manmade factors which are contributing to and resulting in no immunization of the children.